Chemsex: Essentials for Treating the Addictive Fusion of Drugs and Sex

Home , Party and play

Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Presented by: David Fawcett, PhD, LCSW

Webinar Facilitator: Jessica O’Brien, LCSW, CASAC

Training & Professional Development Content Manager

• NAADAC, the Association for Addiction Professionals • www.naadac.org/webinars • [email protected]

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Using GoToWebinar (Live participants only)

 Control Panel  Asking Questions  Handouts  Audio (phone option)  Polling Questions

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Presented by: David Fawcett, PhD, LCSW 1 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

www.naadac.org/understanding-chemsex-webinar

Cost to Watch: Free

CE Hours Available: 1.5 CE

CE Certificate for NAADAC Members: Free

CE Certificate for Non- members: $20

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Webinar Presenter: David Fawcett, PhD, LCSW Vice President for Clinical Programming

• Co-creator of chemsex treatment at Seeking Integrity • Author of Lust, Men and Meth: A Gay Man’s Guide to Sex and Recovery • Executive Producer of Crystal City, available on Amazon Prime

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Chemsex: Essentials for Treating the Addictive Fusion of Drugs and Sex

NAADAC Webinar 2021

DAVID FAWCETT PHD, LCSW SEEKING INTEGRITY

Presented by: David Fawcett, PhD, LCSW 2 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Objectives 1. Attendees will describe meth’s impact on the body and brain, including the fusion of substance intoxication and sexual behavior. 2. Attendees will demonstrate knowledge of best practices for chemsex treatment and the clinician’s role in promoting a sex positive approach, including reducing shame and stigma, to treat fused sex and drug use. 3. Attendees will compile practical steps to help recovering chemsex users untangle drug use, sex and intimacy, thereby reclaiming healthy sexual behaviors and relationships.

Creating Safety

How familiar are you with treating chemsex (sexualized drug use)? 1. Not at all familiar Polling Question 2. Slightly familiar #1: 3. Somewhat familiar 4. Moderately familiar 5. Extremely familiar

Presented by: David Fawcett, PhD, LCSW 3 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

What is Chemsex?

Understanding the fusion of drugs and sex

Chemsex A straight man who uses cocaine and porn before seeing an escort A gay man who uses meth and poppers as part of “party and play” A straight woman who uses opioids and marijuana as part of her sex addiction

Co-occurring drug use and sexual behavior Paired/Fused, ritualized drug use and sex “Chemsex” generally refers to MSM; shorthand here Dopamine driven – with intensity Paired drug use and sex = all genders/ all orientations Can also be cross-addiction

Treating the Whole Addiction Syndrome Too often drug clients are told to get clean and sober and the sex will take care of itself. If often doesn’t… and leads to a less-fulfilling (or nonexistent) sex life or ongoing relapses. Whack-a-mole

Presented by: David Fawcett, PhD, LCSW 4 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Chemsex Most common: •Methamphetamine •GHB/GBL •Cocaine or Crack Cocaine •Ketamine •Ecstasy •Amyl nitrate •Mephedrone (UK) •Alcohol •Marijuana •Other synthetics

Have you observed a trend in co-occurring drug use and sexual behavior where you are located? 1. Never really observed much of it Polling Question 2. Levels seem about the same #2: 3. It's slowly getting worse 4. It's quickly getting worse 5. It's improving

Sex-Drug Connection •Longer periods of preoccupation and sexual intercourse •Careless in choice of partner •No use of condoms •Increased receptive anal intercourse •Increased sexual desire •Tolerance creates need for increased intensity •High relapse risk because of meth-sex fusion

Presented by: David Fawcett, PhD, LCSW 5 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

The Problem NYC Health Department: ◦Deaths from meth overdoses increased 160% from 2013 to 2014. Black gay/bi men are using meth in increasing numbers in New York ◦Counselors at Gay Men of African Descent, a New York-based service agency, say between 20%-40% of clients addicted to meth (2016) ◦6 of 10 African-American MSM predicted to be be HIV-positive by the age of 40. 20% of transwomen use meth1

1. Santos GM, et.al. (2014) Alcohol and substance use among transgender women in San Francisco: prevalence and association with human immunodeficiency virus infection. Drug Alcohol Rev. 2014 May;33. (3):287-95. doi: 10.1111/dar.12116. Epub 2014 Mar 14.

The Problem More than 70% of local law enforcement agencies from the pacific and west central regions of the US report methamphetamine as the greatest drug threat in their area.1

Nationwide, overdose deaths from the category of drugs that includes methamphetamine increased by 7.5 times between 2007 and 2017.2

About 15% of all drug overdose deaths involved the methamphetamine category in 2017, and 50% of those deaths also involved an opioid.2

1. Artigiani EEH, M.H.; McCandlish, D.; and Wish, E.D. Methamphetamine: A Regional Drug Crisis. College Park, MD: National Drug Early Warning System 2018. 2. CDC. CDC Wonder Multiple Cause of Death.

The Problem Antidote, UK's only LGBT drug and alcohol support service: ◦ >60% of clients injected drugs in last year. ◦ Double the number in 2010. ◦ Nine years ago, fewer than 1% were injecting drugs.

University of NSW’s 2015 Sydney Gay Community Periodic Survey ◦ 2,846 men ◦ 10.2% HIV-negative men used meth prior 6 months ◦ >30% used meth prior 6 months

Injection drug use was 34% among MTF transgender individuals and 18% among FTM transgender individuals.1

San Francisco study by Dr. Kristin Clements at the San Francisco Department of Public Health AIDS Office (2000).

Presented by: David Fawcett, PhD, LCSW 6 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Chemsex and MSM Combines drugs (often amphetamines) with sex ◦Often high-risk ◦Party and Play (PNP) ◦Chemsex ◦Methsex ◦Facilitated by social media

Meth epidemic in rural America

Presented by: David Fawcett, PhD, LCSW 7 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Risk Factors

•Trauma •Dissociate from/ Numb uncomfortable feelings: • Shame • Stigma • Fear • “Less than” • “I feel like damaged goods”

•Need for intensity (tolerance) •Intolerant of low stimulation moods/situations (e.g. boredom) •Search for connection and belonging •“Celebrating” sex / transgressive sex

Layers of Stigma Underlie Addiction

◦ Racial/ethnic minority ◦ Sexual minority ◦ Mental health ◦ Substance use problems ◦ Disabilities ◦ Sex Work ◦ Rejection ◦ Discrimination ◦ Social isolation ◦ Financial difficulties ◦ Violence ◦ Suicide ◦ Intracommunity stigma

Adverse Childhood Experiences (ACES)

Abuse Physical, sexual, emotional, intellectual, spiritual

Household Challenges Domestic violence, substance abuse, mental illness, parental separation/divorce, incarcerated parent, sibling with chronic illness

Neglect Emotional, physical

Presented by: David Fawcett, PhD, LCSW 8 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Impact of ACES

1 of 8 have 4 or more ACES ◦ 3x lung disease and smoking ◦ 14x suicide attempts ◦ 4.5x depression ◦ 11x injection drug use ◦ 2x intercourse before age 15 ◦ 2x liver disease

People with 6 ACES die on average 20 years earlier

Sequence of Club Drug Use Initiation

Drug First Second Third Fourth Fifth First: Cocaine Crystal 15 (3%) 84 (19%) 87 (20%) 124 (29%) 30 (7%) Second: Ecstasy Third: Ketamine Ecstasy 154 (35%) 154 (35%) 54 (12%) 16 (4%) 4 (1%) Fourth: Methamphetamine Fifth: GHB Cocaine 285 (59%) 67 (15%) 53 (12%) 19 (4%) 7 (2%)

GHB 0 (0%) 7 (2%) 29 (7%) 59 (16%) 93 (21%) Ketamine 10 (2%) 96 (22%) 134 (31%) 71 (16%) 9 (2%)

Note. Each box contains the number of participants who used the drug for the first time STUDY BUMPS

Presented by: David Fawcett, PhD, LCSW 9 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Underlying Core Beliefs I feel like damaged goods. I am basically a bad, unworthy person. No one would love me as I am. My needs are never going to be met if I have to depend on others. Sex is my most important need.

◦ Multiple stigmatized identities ◦ Stigma & discrimination ◦ History of trauma ◦ Rejection, abuse and violence ◦ Unfair treatment in the legal system ◦ Minority stress ◦ Lack of social, mental health, physical health support ◦ Cognitive escapism

Dopamine and Reward Food Sex Excitement Comfort Nurturing

◦Reinforcement for pleasure, then neural pathway formed: creates tolerance

Dopamine

Dopamine creates a network of cues and triggers. Dopamine heightens desire. Dopamine fuels preoccupation. Dopamine creates tolerance. Dopamine fuses behaviors.

Presented by: David Fawcett, PhD, LCSW 10 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

A. Before habit is learned, dopamine is released when the reward is experienced for the first time. B. Dopamine released after a cue resulting in desire and craving. C. Once learned dopamine not released when reward experienced and will drop if not experienced. D. Highly sensitized to reward coming or not. James Clear Atomic Habits

“Maybe” greatly increases dopamine released once learned (B). Intermittent reward Robert Sapolsky

Tolerance: Need Increasing Intensity

Reinforcement for pleasure, then neural pathway formed: creates tolerance Brain sheds receptors in attempt for homeostasis More drugs/stimulating behaviors required to feel “normal” Creates need for increased intensity Alters arousal template Results in escalating behaviors

In recovery – stimulation drops; anhedonia, depression, impulsivity

Meth and Dopamine Meth flushes dopamine from neuron Meth blocks receptor reuptake Meth is neurotoxic Meth destroys dopamine transporters

Presented by: David Fawcett, PhD, LCSW 11 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Limbic System – Relative Dopamine Reward

Partial Recovery of Brain Dopamine Transporters in Methamphetamine Abuser After Protracted Abstinence

ml/g m

METH Abuser Normal Control METH Abuser (1 month detox) (24 months detox)

Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.

Neurotransmitters and Addiction: Excitatory

SPIKE FIRING EXCITING – INCREASES APPETITE Stimulate positive action potential Pleasure from imagining something we Dopamine desire Glutamate Pornography hyperactivates the appetitive system Epinephrine (Adrenaline) Intensity addictions hyperactive this Norepinephrine system as well Largely dopamine driven

Presented by: David Fawcett, PhD, LCSW 12 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Neurotransmitters and Addiction: Inhibitory

DECREASE SPIKE FIRING SATISFYING - CONSUMMATORY Simulate negative action potential Produces a calming, fulfilling sensation Easily depleted when overactive Such as after sex or a good meal Dopamine Neurochemistry based on release of Serotonin endorphins GABA (Gamma-Amiinobutyric Acid) Similar to opiates Peaceful, euphoric bliss

Limbic System

Gambling, sex Sex Inhibitory Excitatory (power), porn, (security), crises, shoplifting, relationship, work, gaming shopping, tv

ANHEDONIA MANIA DEPRESSION Satiation Arousal

Food, Cocaine, meth, alcohol, diet pills, sedatives, Adrenaline, MDMA opioids GABA, Endorphins Dopamine

Methamphetamine

“Remember when we only had black and white television and then came color TV – it’s the same with methamphetamine and sex.”

Presented by: David Fawcett, PhD, LCSW 13 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Methamphetamine is the Core Molecule

MDPV (a.k.a. Bath Salts)

Ethylone (a.k.a. Molly)

Methamphetamine Methylone (a.k.a. Molly)

Alpha-PVP (a.k.a. Flakka)

Meth Manufacture Variety of methods ◦ P2P, Nazi Method, Red Phosphorous Method, etc. Mom and Pop labs ◦ Sudafed Smurf Mexican cartels ◦ Refined P2P process to industrial scale

Mexican Superlab Production

Presented by: David Fawcett, PhD, LCSW 14 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Methods of Ingestion Smoke Swallow Hot rail Snort Anal Inject

Duration of Action 10-12 hours

Effects of Meth Acute Physical Effects ◦Increases heart rate, blood pressure, pupil size, respiration, sensory acuity, energy ◦Decreases appetite, sleep, reaction time

Chronic Physical Effects ◦Pulmonary hypertension, heart attack, stroke, infections in the heart, t remor, weakness, dry mouth, weight loss, cough, sinus infection, sweating, burned lips, sore nose, oily skin/ complexion, headaches, diarrhea, anorexia

Presented by: David Fawcett, PhD, LCSW 15 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Effects of Meth Acute Psychological Effects:

◦Increases confidence, alertness, mood, sex drive, energy, talkativeness

◦Decreases boredom, loneliness, timidity

Effects of Meth Chronic Psychological Effects

◦Confusion, concentration, hallucinations, fatigue, memory loss, insomnia, irritability, paranoia, panic reactions, depression, anger, psychosis, formication, scarring

Impairment of Facial Emotional Recognition Capacity to identify emotions from facial expression and infer mental state impaired

Implications for empathy

Presented by: David Fawcett, PhD, LCSW 16 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

GHB/GBL

Survey of 5000 people; 2700 were gay or bisexual and had taken “G”

• Sexual violence with G so widespread that almost everyone who had taken it said they knew someone who had been raped or sexually assaulted while on it.

• Over a quarter had been assaulted themselves.

• Young men are drugged with G and raped, filmed and livestreamed over the dark web.

• Overdose is normalized and een as a “rite of passage”.

• One London hospital saw G overdoses almost every day — over 300 in one year.

• G use among heterosexuals is rising.

(Terrence Higgins Trust and the University of Cambridge Survey 2019)

The Fusion of Drugs and Sex

What fires together wires together

Drug-Sex Fusion Dopamine causes bonding

Sexual desire becomes highly focused, meth dependent

Creates complex network of triggers and cues

Sex triggers meth; meth triggers sex – well into recovery

Presented by: David Fawcett, PhD, LCSW 17 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Arousal Templates

• Develop age 4-5

• Can expand

• Difficult to remove elements

• Chemsex:

Focuses template Alters template Tolerance develops

Hijacking the Arousal Template

•Connections to dopamine-rich fantasies become deeply grooved and automatic •Dopamine requires novelty •Requires increasing stimulation, risk, taboo for same effect •Requires a reset from superstimulation •Persistent anhedonia in early recovery

“My sexual tastes and desires morphed into something unrecognizable.” (Client)

Escalation in the arousal template Ideal learning conditions: focus + concentration (+ trance state) o Rougher o More taboo o Groups o Hard-core o More intense

Presented by: David Fawcett, PhD, LCSW 18 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Meth & HAART Interaction The effect of methamphetamine [is] two or three times greater for individuals on combination therapy, especially pharmacokinetic enhancers ritonavir (Norvir) – Protease Inhibitor cobicistat (Tybost) - found in Prezcobix

CYP2D6

Halkitis, Parsons and Stirrat (2001) among others

Recovery

• Most important factors for sustained recovery: • Social Connection • Belonging • Retention

• 12 step programs; SMART Recovery; alternative programs (eg Refuge/Dharma Recovery)

• Long term

• Support and Therapy groups

Implications for Treatment

Decreased verbal Increased visual Prolonged memory memory cognitive • Poor abstract thinking • Heightened acuity and impairment sensitivity

Damaged reward Prolonged circuitry impulsivity • Prolonged problems with mood

Presented by: David Fawcett, PhD, LCSW 19 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Clinical Approaches for Chemsex Be aware of best practices treatment: ◦ Outpatient, short groups, daily for up to a year and beyond (esp for stimulants) ◦ Inpatient may provide safety (psychiatric sx, environmental cues, etc.) Be alert to poor insight and judgment Be alert to impulsivity Be aware that “denial” may be fuzzy thinking Assist with breaking drug/sex triggers and instilling new behaviors Utilize the brain’s reward system

Tasks Following Engagement in Care Get a physical workup ◦May have not been adherent to HAART ◦May have meth-related complications (HTN, pulmonary hypertension, stroke risk, liver and kidney issues) Get a psychiatric workup ◦Persistent paranoia, depression, hopelessness, suicidality

Check status of supports, resources, safety

Therapist’s Role Addressing Chemsex Treatment ◦Matrix Model Crisis stabilization Thorough bio-psycho-sexual assessment Sequence ◦Traditionally treat substance use first ◦For most meth-using gay men must treat co-occurring stimulant use and sex addiction simultaneously Develop drug relapse prevention plan Develop sexual boundary plan

Presented by: David Fawcett, PhD, LCSW 20 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Therapist’s Role Addressing Chemsex Address underlying issues (shame, trauma, anxiety, depression, etc.) Various modalities: CBT “light,” motivational interviewing, contingency management Individual & group therapy; 12 step or other support group ◦What about CMA?

The Worker: Must Be Self-Aware Understand one’s own feelings ◦Manage, contain, seek supervision Become conscious of one’s biases Become aware of one’s defenses ◦Avoid, ignore, laugh, divert, reinforce Must avoid re-shaming and re-stigmatizing Boundaries!

Change Beliefs Braun-Harvey: ◦Believe in ability to maintain recovery and have active, pleasurable and emotionally meaningful sex life. Discover/define one’s personal healthy sexual expression

Presented by: David Fawcett, PhD, LCSW 21 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

Steps to Reclaiming Healthy Sexuality Not a linear process Identify and change sex-drug behavior patterns Learn to manage feelings “Second coming out” Involves: ◦Healing shame and stigma ◦Cultivating hope, gratitude and purpose ◦Developing healthy connection with self, partner, friends, community ◦Addressing history of trauma ◦Revisiting concerns about HIV/Hep C status (if positive)

www.seekintegrity.com www.sexandrelationshiphealing.com

Contact

[email protected] www.seekingintegrity.com www.sexandrelationshiphealing.com

Presented by: David Fawcett, PhD, LCSW 22 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

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Presented by: David Fawcett, PhD, LCSW 24 Chemsex: Essentials for Treating the 6/23/2021 Addictive Fusion of Drugs and Sex

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Presented by: David Fawcett, PhD, LCSW 25